Provider Demographics
NPI:1073838124
Name:JACKERSON, AMELIA BETH (MED, MA, OTR/L)
Entity type:Individual
Prefix:MS
First Name:AMELIA
Middle Name:BETH
Last Name:JACKERSON
Suffix:
Gender:F
Credentials:MED, MA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3770 ALABAMA ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-3304
Mailing Address - Country:US
Mailing Address - Phone:310-741-9989
Mailing Address - Fax:
Practice Address - Street 1:6991 BALBOA AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3447
Practice Address - Country:US
Practice Address - Phone:858-496-8232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12176225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics